Revision Roundtable BONUS - ASIS/AIIS Double Osteotomy

Send us a text

Find the video version here: https://youtu.be/VvwETRRkQxc

Meet our guest surgeons:
Dr. Kris Alden - https://www.krisalden.com/
Dr. John Horberg - https://www.premierboneandjoint.com/meet-dr-horberg
Dr. Aldo Riesgo - https://my.clevelandclinic.org/staff/22587-aldo-riesgo
Dr. Jonathan Yerasimides - https://www.louisvillehip.com/
Dr. Charles Lawrie - https://baptisthealth.net/doctors/charles-m-lawrie/1888379

Register now for AHF 2025 in Nashville, TN! https://anteriorhipfoundation.com/ahf2025-nashville/

Check out Dr. Yerasimides Anterior Approach Masterclass (including episodes on Acetabular and Femoral Revision) on YouTube! Find the playlist at https://www.youtube.com/playlist?list=PLDzGqZUR760dlZ8i9H78ZQuKRfBW5pXe7

Exploring Advanced Osteotomies with Dr. Aldo Riesgo

In this bonus episode of the AHF podcast, host Joe Schwab welcomes Dr. Aldo Riesgo to discuss the intricacies of anterior superior iliac spine (ASIS) osteotomies and the combination of ASIS and AIIS osteotomies. Dr. Riesgo delves into the technical details and benefits of these approaches, particularly in challenging cases involving infection, significant bone lengthening, and complex pelvic reconstructions. Throughout the discussion, emphasis is placed on bone-to-bone healing, reducing morbidity, and continuous improvement in surgical practices. Additionally, the episode highlights the value of collaboration and innovation in orthopedic surgery.

00:00 Introduction and Episode Overview
00:44 Discussion on ASIS Osteotomy
01:38 Double Iliac Osteotomy Technique
02:31 Case Study: Cadaveric Dissection
03:46 Managing Complex Defects
07:16 Innovations and Future Directions

Episode Transcript

Joseph M. Schwab (00:00):
This is Joe Schwab host of the AHF podcast.

(00:03):
The response to our revisionround table series has been
tremendously positive.
So this week, just like lastweek, we have another bonus
episode with content that justcouldn't make it into the
original episodes.
This week, we've got Dr.
Aldo Riesgo talking aboutanterior superior iliac spine
osteotomies, and combined ASISand AIIS osteotomies.

(00:29):
And just like last week, you cancheck the show notes for links
to the video.
Now let's get on with the AHFrevision round table.

Jonathan Yerasimides (00:44):
Aldo what do you think the ASIS osteotomy,
gains you as far as, access?
And are you taking that, are youtaking that bone fragment
medially?

Aldo M. Riesgo (00:55):
look, I think it allows me to start going down
the slide, I like to call it.
Go down the anterior column, gointo the pelvis, I flip that
tissue medial, right?
And then I start working.
I do a lateral window kind ofexposure and then walk it down
the anterior column to get to,to my pubis.

(01:16):
I think it's a, I think it's alow morbidity thing.
I like bone on bone healing.
I like to leave some of thatattached.
I've set them up now wherethey're angled.
So if I have a shortening caselike John's mentioned before,
you can slide the osteotomy downso you can still get bone to
bone healing.
You don't want to completelyflat cut.

(01:38):
yeah, so I've been messingaround with a double kind of a
double Iliac osteotomy, ASIS andAIIS.
Cause I had some of my youngerpatients, when I needed more
access and I was always doing afemoral rectus femoris tenotomy.
So I've started, doing it, thisdouble osteotomy to leave the
rectus attached.
So here's a good case, I got toget into the pelvis, extremely

(02:04):
short, I'm gonna have tolengthen this patient, so this
person's another infection case,bilateral primary hip some many
years ago.
So I'm going in, if you see theinitial exposure, I have a
picture there, You're nevergoing to get to the trunnion.
That's the anterior coding ofhis femur, right?

(02:24):
So that's where his ASIS isbefore I decided to do any work.
So I need to access the innertable to even get this
dislocated.
This is a cadaveric picture, butif you see here, this is what it
looks like.
So there's a, if you clickahead, that's where my ASIS
osteotomy would be.
That piece of bone right aboveit is the superior spine.
And then you angle it like a 45degree or 60 degree angle, and

(02:48):
then you don't want to extend ittill you get into your dome,
right?
So this is a cadavericdissection where we've put a cup
in and we've already markedthat.
And then if we keep going, I'llmark it there, ASIS, AIIS.
And then in patients where youdon't have a lot of shortening,
you can actually get a bone tobone.
Repair that.
So this is back to that case.

(03:09):
There's that, pseudoacetabulumthat's formed at the top and the
inner table.
that's where I did theosteotomy.
You can see that right there.
That's the piece of bone rightthere.
and then I can then hookretractors underneath that.
I use a Charnley.
So that Charnley's hooked aroundthe AIIS and then I can walk
down the column.
My sucker tip is pointing atthat osteotomy.

(03:32):
so there I went ahead and,unroof the socket from the
inside.
and then, yeah, I was able to, Iwas able to, dissociate the
trunnion and the head ball

Jonathan Yerasimides (03:44):
Say, cause that, that looked like contained
defect.
Like when you show me that APpelvis, I wasn't thinking the
anterior column was going to beout.
I thought this looked like justa giant superior contained
defect, that picture there, sodid you create like an anterior
column hole then so you couldget

Aldo M. Riesgo (04:00):
Yes, yeah, so this is an infected case.
I had to get a really gooddebridement and I couldn't even
access that thing was not thatthing was socked in he was up
and in that for years This guywas a neglected pji case it took
over a year and a half to gethim on my schedule not the best
social situation for him sothere's no way I was gonna even

(04:23):
be able to get that cup andtrunnion even out of the pelvis
without doing this.
So yeah, whenever I have to getinside to the, yeah, I think
recreating a column defect,that's a great indication for
it.
But for me, this is just gettingthe parts out.
I had to get the parts out.

Jonathan Yerasimides (04:39):
Yeah, no, and I've done that before where
I've had these giant containeddefects.
And then just to get theimplants out, I ended up
creating an anterior column,anterior wall defect, just to
get the parts out and then fixthem later.

Aldo M. Riesgo (04:54):
yeah, a case like this where he was short
five centimeters.
I think direct anterior is theway to go because.
I can do an extensive releaseoff the outer table.
I think the abductor mass andthe TFL will slide down to a new
position.
And then I, if you angle theseosteotomies, you can, slide them
down a bit.
for this guy, getting him backfour or five centimeters, you're

(05:16):
probably not going to get boneto bone contact when you repair
it, but I do have a, a picturecoming up and an X ray of,
that's what we did for this guy.
you can actually put thoseplates on the inner table.
If you have incredible access toit.
So that's a good, that's a goodfunctional spacer for him.
He's a pretty low demand guy,but then in my, more functional

(05:39):
patients where I've had to doit, I do fix it.
Yeah.
If you show that next picture,you can see those screws where
the ASIS and the AIIS are, youcan get great bone to bone.
Healing right there of the kindof double osteotomy.
So this guy's, this patient herethat I showed different patient

(06:00):
obviously, but this guy is 42years old, I would, tenotomize
the rectus on most of thesepatients and I think they would
have some persistent.
Hip flexor strength.
So I've started doing this andI've been pretty happy with the
results so far.

Jonathan Yerasimides (06:17):
Have, do you always double osteotomy or
is it possible?
And I'm asking just cause I'venot done it.
I don't know.
but taking, taking them both inone osteotomy, the ASIS and the
AIIS and just making it onelarge fragment because you might

(06:38):
be getting down into a littlebit of the dome, but you're
still, you're posterior columnwhere we bear our weight and
where we're loading our implantsand still be intact.
I don't know if you've evertried to take one piece or not.
Yeah,

Aldo M. Riesgo (06:51):
yeah I think that's the that's the next
iteration of this if I can do itand obviously everyone's pelvis
morphology You look at it liketheir angles are a little bit
different in terms of youObviously don't want to
compromise the bone that youneed for reconstruction.
I think that's the number onekey and you mentioned that So
for right now, I've just beendoing Double.
but I think then if I could doit all as one big piece, that

(07:13):
would probably be better andeasier, truthfully.
But I think that what that justgoes to show is every year I'm
doing more and more of these.
And I think we're allexperimenting and pushing the
envelope as to what is best forour patients.
And so far so good.
I've had, on the few patientsI've done this on, they haven't

(07:34):
really given me the samecomplaints that I was getting
before, in terms of some ofthat, rectus or hip flexor
weakness.

Jonathan Yerasimides (07:43):
I'll give a shameless plug out to one of
your, one of your, old fellows,James Baker.
I just did a course with himand, he's, I'll take a little
credit.
He was my resident, but he wasyour fellow, but, he, he's,
doing some wild stuff down herein Louisville.
He's, on the radar.

Aldo M. Riesgo (08:04):
Yeah.
Yeah.
I think we're, but again, it'sabout training that next
generation of guys who are,we're, we are not set in our
ways of Hey, this is how we didit.
And this is how people havealways done it.
And this is how we need to keepdoing it.
No, we haven't perfectedanything.
And I think that's part of thegoal of all this is being
collaborative.
And I've picked up a lot ofstuff from, everyone here that

(08:26):
I've talked to about, about howI do hips and how I do
revisions.